Injury, Int. J.

Care Injured 47 (2016) 11621169

Contents lists available at ScienceDirect

Injury
journal homepage: www.elsevier.com/locate/injury

Review

Whats new in the management of complex tibial plateau fractures?

Zinon T. Kokkalis, Ilias D. Iliopoulos, Constantinos Pantazis, Elias Panagiotopoulos *
University of Patras, School of Medicine, University Hospital of Patras, Department of Orthopaedics, Papanikolaou 1, 26504 Rio-Patras, Greece

A R T I C L E I N F O A B S T R A C T

Keywords: The management of complex tibial plateau fractures is ever evolving. The severity of the injury to the
Tibial plateau fracture surrounding soft tissues inuences the timing and the method of xation. Minimal invasive techniques
Augmentation continue to dominate our philosophy of reduction and reconstruction whereas augmentation of
Minimal invasive technique depressed intra-articular fragments remains an accepted strategy to maintain reduction and prevent
Locking plates
secondary collapse. Locking plates, conventional plates and ne wire xators all have been used
successfully with satisfactory outcomes. In this article we report on the latest advances made in the
management of these complex injuries.
2016 Elsevier Ltd. All rights reserved.

Contents

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1162
Denition and classication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1163
Incidence and presentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1163
Treatment options and clinical results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1163
Temporary external xation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1163
Open reduction and internal xation (ORIF) evidence for approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1164
Arthroscopically-assisted reduction and internal xation (ARIF) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1165
External xators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1165
ORIF vs. Ex-Fx . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1166
Latest data and innovative techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1166
Recommendations conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1166
Conict of interest statement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1166
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1167

Introduction degree of bone comminution reects the energy transmitted to the

Complex bicondylar fractures of the tibial plateau remain a
challenge to even the most experienced surgeons. The anatomy of
the tibial plateau, combined with high energy trauma, produce
complicated injury patterns with involvement of metaphyseal
and articular comminution and frequently with loss of integrity of
the soft-tissue envelope. The severity of soft tissue injury and the
* Corresponding author at: Orthopaedic Department, Patras University Hospital,
26504, Rio, Patras, Greece. Tel.: +30 2613603555; fax: +30 2610994657.
E-mail addresses: drkokkalis@gmail.com (Z.T. Kokkalis),
ecpanagi@med.upatras.gr (E. Panagiotopoulos).
bone and incline to unfortunate prognosis [1,2].
In these severe cases the goal of treatment is the recovery of the
articular surface and the reduction of the anatomic alignment of
the lower extremity. However, what is crucial in deciding the time
and modus of the surgical intervention is the status of local soft
tissues.
Modern operating techniques focus on the maintenance of the
integrity and vascularity of the injured soft tissue and it seems that
biologic approach of these intrarticular fractures achieves to lessen
their morbidity [3,4].
We discuss current treatment options and results reported in
the literature, in an attempt to shed some light in the demanding
procedure of complex tibial plateau fractures management.

http://dx.doi.org/10.1016/j.injury.2016.03.001
00201383/ 2016 Elsevier Ltd. All rights reserved.

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Denition and classication
Schatzker et al. in 1979, classied tibial plateau fractures into
six groups, each representing similar injury mechanism and
fracture pattern, resulting in similar management difculties [5].
Complex fractures, most of the authors regard as AO type C or
Schatzker type V and VI, can be dened as intra-articular lesions,
involving osseous compromise of more than one distinct
anatomical areas of the proximal tibia, with a variable degree of
comminution and soft-tissue damage. Type V fractures are
bicondylar, occurring as a result of an axial thrust in knee
extension, with varying degrees of metaphyseal comminution and
usually no depression of the articular surface [6]. Type VI fractures
are characterised by meta-diaphyseal extension of the fracture line
separating metaphysis from diaphysis presented with various
degrees of articular and metaphyseal comminution [6].
However, both Schatzker and AO classication, as AP radio-
graph-based systems, somewhat fail to adequately identify and
describe posterior shearing fracture patterns, which subsequently
leads to poor clinical relevance with a negative impact on
treatment plan [7,8]. Incidence and distinct clinical characteristics
of these high-energy related fractures have been gaining attention
over the last years, due to their highlighted poor compliance to
conventional treatment methods and surgical approach [912].
With his recent research, Luo et al. introduced the Three
Column Classication, based on CT axial view and 3D reconstruc-
tion as a supplement to the Schatzker classication, dividing the
tibial plateau in three columns each dened according to anatomic
location and corresponding surgical approach achieving high
therapeutic correlation [7,13].
Incidence and presentation
Tibial plateau fractures account for 12% of all fractures and
8%of fractures in the elderly [14]. Albuquerque et al. in 2013 study of
239 tibial plateau fractures surgically treated in a level I trauma
hospital, reported a 36% incidence of Schatzker V and VI type,
associated with high-energy injury mechanism involving car/
motorcycle accidents or high altitude falls [15]. They also demon-
strated a male to female predominance of approximately 7030%,
with a mean occurrence age of 43.7 years.
These severe-trauma related injuries produce comminuted
fractures with signicant soft tissue damage, as well as disruption
of primary and secondary knee stabilisers [16,17]. In a 2010 study,
Stannard et al. reported an incidence of torn ligaments following
tibial plateau fractures, as high as 85% and 79% in type V and VI
respectively [17]. However, this type of injury is also becoming
more and more prevalent in the elderly, as consequence of low
energy falls and osteoporosis [18]. In such cases, soft tissue damage
arises from the delicacy of the skin. The dissociation of the
metaphyseal are from the diaphyseal columns and the status of
the soft tissue envelope, can typically represent the severity of the
energy imparted to the bone [5,19,20].
Schatzker V and VI fractures have a notoriously high incidence
of compartment syndrome that can reach 30.4% for type VI in some
studies [21,22]. Compartment syndrome may develop several
hours or more after the injury and post-operatively. Pallor,
pulselessness, paresthesiae are late signs of compartment syn-
drome, but patients should be treated with fasciotomy prior to
developing these [23].
Radiographic evaluation of these fractures involves four views:
anteroposterior (AP), lateral, internal oblique and external
oblique. It is useful a 108 craniocaudal angle in AP view in order
to represent normal proximal tibias posterior slope. Computed
tomography (CT) is of great value for determining the location and
magnitude of the joint depression, enabling greater precision of
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1163
preoperative planning, while 3D reconstructions provide an
estimation of metaphysical bone loss, of articular comminution
and joint depression.
The importance of CT evaluation was best demonstrated
through the identication of postero-medial and postero-lateral
shear fractures as a distinct subtype of complex bicondylar tibial
fracture prone to be missed by AP radiograph [13,24]. Higgins
et al. in his 2007 comparison of lateral LCP xation to dual plate
xation and Luos three-column approach, highlighted the clinical
importance of identifying these posterior coronal fracture
patterns while Barei et al. in 2008 showed a postero-medial
fracture component to exist in nearly one third of the bicondylar
plateau fractures [11,13,25].
However, controversy exists in the literature, as to whether
routine CT evaluation can provide greater concordance regarding
Schatzkers classication and contribute towards changes in
preoperative planning in comparison with plain radiographs
[2632]. Both Chan et al. in 1997 and Markhardt et al. in 2009,
concluded that the addition of CT scan signicantly increasesin-
terobserver and intraobserver agreement on treatment plan,
while Te Stroet et al. in his 2011 study, disputed former evidence
reporting no signicant advantages over the use of CT scan and
concluded against its routine use [26,27,29]. In accordance with
Stoets results, latest research from de Lima Lopes et al. in 2014
reported no greater concordance regarding Schatzker classica-
tion and only moderate effect on Luos three-column classication
concluding that larger studies are needed to decide on routine
use [7,33].
Similarly, the formerly suggested capability of an early MRI
scan to identify ligamentous or meniscus lesions and affect
concordance is questionable by latest research [17,18,34,35].
Treatment options and clinical results
All kinds of stabilisation, from non-operative treatment, to
modern staged and combined management with temporary
external xators, prior to conventional or angular stable plating,
ne-wire devices or even arthroscopically assisted procedures and
nailing for selected cases have been recommended in the literature
for complex tibial plateau fractures [5,3642]. Adequate xation
and early motion are important for a good prognosis and satisfying
postoperative functioning [43,44]. In the era before ORIF,
Rasmussen back in 70s presented acceptable results with
conservative treatment but recognised increased incidence of
posttraumatic arthropathies and malunions, while non-operative
management remained a supported option till several years later
regarding complex injuries [36,37,45]. Targets of denitive
treatment should be from one hand restoration of the articular
surface and from the other hand the restoration of tibial length and
alignment, by rebuilding metaphyseo-diaphyseal comminution.
The basic principles for all articular fractures imply rigid xation
for the articular block and indirect reduction with relative stability
for the metaphysic foundation of the knee joint [46].
However, what is crucial in deciding the time and modus of the
intervention is the status of local soft-tissues which, along with
patients co-morbidities, lead the time of denitive xation since
early incisions through compromised skin could become disas-
trous.
Temporary external xation
Casts, splints, traction, and braces are some options for initial
damage control treatment for severe cases, nevertheless, the
optimal temporising treatment is spanning external xation
[38,47,48]. Staged management with standardised protocol is
evaluated by Egol, reporting low rate of wound infections (5%) and
1164 Z.T. Kokkalis et al. / Injury, Int. J. Care Injured 47 (2016) 11621169
relative low rates of complications, with a possible downside of
residual knee stiffness [49]. Spanning external xators reduce
fracture fragments via ligamentotaxis, along with providing pain
relief and a stable environment for soft tissue healing, as well as
early mobilisation of the patient. Antero-lateral pin positioning for
the femur has been found to combine convenience when lying in
bed, along with minimal quadriceps muscle damage, and is
suggested even at the expense of a somewhat less stable
biomechanical construct, whereas tibial half-pins should be placed
in accordance with future incisions and plate positioning [38].
Open reduction and internal xation (ORIF) evidence for approach
Dual plating (Fig. 1) of both medial and lateral compartments
with buttressing conventional plates through a single midline
incision, can achieve rigid anatomic xation for the articular
components and has been considered the gold standard of
Fig. 1. A 31 year-old male with a displaced bicondylar tibial plateau fracture
(Schatzker V) treated in our institution according to staged-management protocol
principles, initially with a spanning Ex-Fx. (A) Primary X-ray evaluation (AP and
lateral views), (B) 2 weeks after the spanning Ex-Fx he was treated with a double
incision/double buttress plating plus screws, achieving good alignment and
articular reduction. Postoperative Images 3 months after the injury.
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treatment for managing bicondylar tibial fractures, since the
initial recommendation by Schatzker back in 1979 [5,19,50,51].
However, subsequent high rates of soft-tissue complications and
nonunion reported in the literature, involving wound dissociation
and deep infection up to 88%, gave birth to an ongoing debate
concerning surgical approach and different implant constructs in
an attempt for a biomechanically adequate but more biological
osteosynthesis [20,50,5254].
Over the next years, several authors adopted the double incision
technique (postero-medial/antero-lateral) for dual plating, report-
ing lower wound complication rate and less adverse effects [18,55
59]. Barei et al. in his 2004 study of 83 complex bicondylar tibial
fractures treated with dual plating using 2 separate incisions,
reported an 8.4% of deep infection while for Jiang et al. in 2008 (84
patients) and Zhang et al. in 2012 (79 patients) the percentages
were 4.7% and 3.8% respectively showing a distinct decrease in
infection rates to the previously reported with single incision
procedures [55,56,58].
However, latest studies attempt to revise the current concept
over single midline incisions effect on soft-tissue envelope
compromise regarding complex tibial plateau fractures and dual
plating. Both Cho et al. and Hassankhani et al. in their recent 2013
case series, suggest single anterior incision for ORIF of Schatzker V
and VI fractures, in order to exploit the advantages of unobscured
exposure of the fracture site and compatibility with a possible
later salvage arthroplasty, reporting zero nonunion incidence and
no infection for Chos 10 patients and a 9% rate for Hassankhanis
22 cases, conrming in a way the previously mentioned value of
delicate handling of tissues and staged management [60,61].
Apart from approach-related technique improvements, the
introduction of angular-stable plates including Less Invasive
Stabilisation System (LISS) and locking compression plates (LCPs)
along with MIPO technique, offered the potential for a low
implant-prole xation able to provide adequate stability in a
severely comminuted or osteoporotic environment [62]. These bio-
friendly implants have been used in various combinations with
conventional plates or screws to achieve proper xation, with the
hybrid lateral-LCP/medial-buttress dual plating and the more
daring single-lateral LISS/LCP with or without lag screw xation
more widely adopted.
In terms of construct stability and reduction loss, it has been
proven that there is no signicant difference between LCP/buttress
and conventional double buttress xation [63,64]. Regarding dual
plating, either hybrid or conventional, satisfying results have been
reported in the literature over the last years with postoperative
malreduction and nonunion rarely reported and a reduction loss
rate of 4.6513.3% in recent studies [58,6365]. Interestingly, a late
retrospective study of 2015 by Rufolo et al. presenting 140
bicondylar tibial plateau fractures under staged treatment protocol
with dual plates through double incision, gives less optimistic
numbers, reporting an overall major complication rate of 27.9%,
including deep infection in 23.6% and 10% nonunion [66].
The use of a single lateral LCP/LISS plate, xing the lateral
condyle and aiming the secure capture of the opposite condyle
without medial buttressing through a single lateral incision has
been producing some mixed results [3,49,58,6769]. Egol et al. in
2004 reported 95% union in 38 patients with complex tibial plateau
fractures treated with unilateral LISS xation, concluding in favour
of the system and Ikuta et al. in 2007 reported 75%/25% excellent/
good functional outcome for 12 Schatzker V and VI fractures with
no complications, but only a 12-month follow-up [49,68].
On the other hand Gosling et al. in his study of 68 patients with
69 AO 41-C fractures concluded that unilateral LISS xation can be
a good alternative, but commented that reduction technique for
exact alignment is demanding, reporting 23.5% of immediate
postoperative malreduction and 9% of loss of reduction [67].
 Z.T. Kokkalis et al. / Injury, Int. J. Care Injured 47 (2016) 11621169 1165

Indeed, Barei et al. in 2008 identied a postero-medial fragment in
1/3 of the bicondylar fractures evaluated, commenting on possible
implications when trying a single lateral xation using angular-
stable implants and Weaver et al. in 2012 reported signicant loss
of reduction and subsidence for the single-plate xation group
when a medial coronal fracture line was present [10,11].
However, literature still remains unclear over the matter and
contradicting results are being published. Ehlinger et al. in 2012,
studied 20 patients with complex tibial plateau fractures,
including medial component, treated with a single lateral LCP
and found the osteosynthesis adequately stable, supporting the
effectiveness of this type of xation [70]. On the contrary, Lee et al.
in 2013, reported a 6.7% malreduction and 20% loss of xation in a
retrospective study of 15 patients with AO 41-C fractures,
commenting on possible limitations of the method in regard to
certain fracture patterns and suggesting he use of a medial
buttressing plate in the presence of medial component [71].
Unusual morphological characteristics of the posterior coronal
fracture pattern may lead to single lateral xation implications,
but also, pose difculties in reducing through conventional 2-
incision technique and has thus opted several authors to come up
with different ideas [13,24,7275]. Lobenhoffer et al. in 1997,
presented a postero-lateral approach with bula osteotomy with
adequate exposure and satisfying results and Frosch et al. in 2010,
presented a modied less traumatic version with preservation of
the bula with good results [73,74]. In 2010 Luo et al. introduced
the CT-based three-column xation concept using an inverted
L-shaped posterior approach combined with an anterior-lateral
approach to safely x all three columns and was followed by
other authors describing slight modications based on the same
concept [13,24,75].
Arthroscopically-assisted reduction and internal xation (ARIF)
In an attempt to address high soft-tissue related morbidity in
complex tibial plateau fractures, avoiding arthrotomy and exces-
sive dissection while maintaining adequate visualisation, arthros-
copically-assisted reduction combined with either conventional
plating or MIPO techniques has been introduced.
ARIF has been widely accepted as a safe method for the
treatment of Schatzker IIV fractures also providing direct
diagnosis and treatment of meniscal and ligamentous injuries
and removal of loose fragments, but still remains controversial
regarding V and VI injuries for several authors [42,7680]. Herbort
et al. in a recent 2014 study of ARIF outcome on Schatzker I-IV
equivalent fracture types, clearly identies complex tibial
plateau fractures as contraindications due to high danger of
iatrogenic compartment syndrome from uid extravasation,
even though its actual occurrence is reported extremely rarely in
the literature [79,81,82].
However, there is evidence in the literature to support the
safety of the method along with good results when performed by
experienced surgeons [8385]. Chan et al. and Chiu et al. reported
on 18 and 20 patients with Schatzker V or VI fractures respectively
each showing approximately 90% (8992%) good or excellent
results and no complications [83,84]. In a most recent systematic
review by Chen et al. in 2015, the authors nd this treatment
option to be safe and with fewer complications regarding
bicondylar fractures, whereas concerning ARIF vs. ORIF compari-
son the former shows lower incidence of infection but based on
limited data [86].
External xators
Fine wire external xation (Fig. 2), using circular or hybrid
frames, gained popularity as it allows for early and adequate initial
weight bearing without limitations related to skin condition and is
considered the ideal method of treatment for cases where
extensive dissection and internal xation are contraindicated
due to trauma of the soft tissue envelope, deciency of bone stock,
and bony comminution [87]. Hybrid xators like Taylor frame and
Ilizarov circular xator have been used effectively for denitive
treatment of complex plateau fractures but with some concern
over the associated elevation of pin tract infection risk and
inadequate reduction [88,89]. Moreover, external xators must be
maintained until sufcient healing has occurred, which makes
patients acceptance and compliance difcult.
In his retrospective evaluation of 15 open comminuted tibial
plateau fractures treated with a circular xator in 2007 study,
Subasi et al. reported acceptable results but noted insufcient
anatomical reduction and loss of reduction in comminuted
posterior wall fractures in the coronal plane [89]. To address
reduction issues, several authors reported good results using a
hybrid or circular frame combined with minimal open reduction
and percutaneous screw xation, femoral frame extension or even
grafting, through a small skin incision in cases with severe
comminution and metaphyseal osseous gap [9094].
Complication rates related to surgical site infection in the form
of pin tract or deep infection vary in the literature. Hutson et al. in
his meta-analysis of 16 studies including 568 patients gave a 10%

Fig. 2. 63 year-old male with a complex tibial plateau fracture (Sch. V) and severe soft tissue trauma after motorcycle accident. (A) Initial AP and lateral views, (B) immediate
postoperative views after treatment with combined lateral mini arthrotomy and xation under uoroscopy with 2 lag screws + mixed autologous/synthetic graft and
application of an Ilizarov device with 1 full circular ring distally and 2 semi-circular (5/8 conguration) proximally/3 wires each (olive wire through head of the bula).

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1166 Z.T. Kokkalis et al. / Injury, Int. J. Care Injured 47 (2016) 11621169
pin tract infection rate for tibial plateau fractures and similar
results were reported by Babis et al. (9.1%) and Kataria et al. (13.2%)
in their studies of 33 patients including 5 open fractures and 38
patients including 4 open fractures respectively [91,95,96]. When
only open complex tibial plateau fractures are examined in 2013s
study, Ali et al. reported a 20% rate of pin tract infection and 1 case
of deep infection in 25 patients treated with a circular xator [97].
ORIF vs. Ex-Fx
Several studies have been presented in the literature over the
past years comparing internal xation methods to external hybrid
or circular frames in relation to different outcome aspects with no
clear results. In a 2002 biomechanical study, Watson showed that 4
tensioned olive wires across the fractured tibial plateau can
provide better stability than dual plating, while Ali et al. in 2003 in
a sawbones study produced similar results comparing failure load
between dual plating and two-ring hybrid xator with lag screws
[98,99]. In 2008, Mahadeva in his a review article comparing ORIF
vs. Hybrid xation in Schatzker VI tibial plateau fractures, cannot
establish statistical superiority of the hybrid frame since residual
deformities remain high and functional outcome poor in both
groups [100].
On the theoretical advantage of respect of soft tissue envelope, a
circular external xator can correlate to lower infection rates, less
intraoperative blood loss, shorter hospital stay and less unplanned
revision surgical interventions in comparison with dual plating as
shown in 2009 by Halls RCT study [101]. However, when it comes
to functional outcome, Halls results, in accordance with the more
recent Chan et al. and Ahearn et al. research including both
conventional and angular stable plating, fail to produce signicant
differences [102,103].
Latest data and innovative techniques
Latest research concerning the ORIFEx-Fix comparison still
fails to enlighten surgeons in terms of functional outcome. Yu et al.
in their 2015 review, show increased correlation to malunions,
knee instability and post-traumatic arthritis for the Ex-Fx group in
contrast to increased valgus deformity, heterotopic ossication
and higher local irritation risk of the plating group with no
differences on mean union time, range of motion and rate of
reoperation [104]. The authors also report less than 90% good/
excellent results for high-energy fracture series, independently of
the assessment tool used, while Huang et al. in 2015 study,
proposes the use of 3D printing and digital technology in order to
enhance preoperative planning of ORIF procedures, concluding
that this method can improve the effects of internal xation [105].
An alternative option in the treatment of specic fractures in
osteoporotic patients is tibial nailing. The technique is described by
Garnavos et al. and could offer an optimal treatment option in the
management of complex intra-articular fractures of the proximal
tibia without signicant impaction that occur in fragile patients
[41]. Garnavos describes good results in low demand patients and
advantages in terms of a minimally invasive procedure that can
allow rapid mobilisation of the knee joint. Further support was
added by 2013s biomechanical studies of Lasanianos et al. and
Hogel et al. reporting resemblance to single lateral locking plate
xation and similar or even increase in the implant-bone construct
stiffness [106,107]. Furthermore, with his 2014 study Garnavos
et al. proposed retropatellar approach, to address intra-operative
problems of visualisation and reduction maintenance related to
free-hanging position previously described [108,109].
However further research comparing retropatellar nailing with
compression bolts to conventional treatment options is needed
and for the time being this method remains an option only for
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highly experienced trauma surgeons and in selected cases. A
variety of surgical approaches have been used previously for the
open reduction and internal xation of the fractures of lateral and
posterolateral tibial plateau. However, the commonly used lateral
approach does not provide adequate exposure and access to the
posterolateral aspect of the lateral tibial plateau. Lately, a number
of different approaches for the management of tibial plateau
fractures have been described. Approach selection should be based
on fracture pattern, the surrounding soft tissue envelope, and the
patients overall clinical conditions. Osteotomies that have been
described for posterior lateral fracture patterns include the lateral
femoral epicondyle osteotomy, bular head resection osteotomy,
and a novel digastric bular osteotomy. A posterior reversed
L-shaped approach (PRLA) has also been used with good results of
fractures involving the posterior column facilitating excellent
visualisation of the medial and posterior tibial plateau [110112].
With regard to depressed articular impaction injuries, there is
sufcient evidence supporting the use of bone graft substitutes for
maintenance of reduction and prevention of secondary fracture
collapse [113]. Recently, the use of minimal invasive techniques
using balloon ination and cement augmentation has become
popular with very good radiological and functional results [114].
Recommendations conclusion
What seems obvious through this attempt to synopsise on the
current literature evidence, regarding the treatment of complex
tibial plateau fractures, is the high degree of controversy still
remaining in different aspects of the management procedure.
Most authors agree, that functional outcome of complex tibial
plateau fractures is primarily dependent on quality of articular
reduction and fracture type can be considered as an independent
predictor [65,115123]. However, fracture patterns of such
complexity and variability, combined with different severity
soft-tissue trauma and patient or institute related issues, along
with the vast selection of available xation methods, makes it
rather difcult to homogenously group these lesions and produce
reliable results in the form of golden standard of treatment.
It is the authors belief, as trauma centre professionals, that the
key to successful surgical treatment in such severe cases, is a well-
designed surgical scheme tailored on the specic fracture type
and soft tissue condition, combined with a high level of surgical
skill and experience. In any case, soft-tissue healing has to be the
rst priority, from the admission of the patient and early damage
control, while best possible anatomical reduction of the intra-
articular fragments should be the second priority to delicate
successful outcomes.
We strongly recommend staged-management procedures and
careful selection of the time of the denitive intervention. For the
denitive xation, both ORIF with dual plating and Ex-Fx with
circular xators have been proven more than adequate in clinical
practice, but in the hands of experienced trauma surgeons. For
ORIF, the traditional and the newly suggested approaches allow
xation of posterior medial, posterior lateral and true posterior
fracture patterns. Single lateral LCP/LISS xation is to be
recommended in cases of osteoporotic bone, but in complex
fracture patterns, the authors feel that CT evaluation of the medial
component is necessary to rule out a coronal fracture line which
could compromise reduction and xation stability necessitating
additional xation of the posterior medial fracture component.
Conict of interest statement
All authors disclose any nancial and personal relationships
with other people or organisations that could inappropriately
inuence our work. There are no potential conicts of interest
 Z.T. Kokkalis et al. / Injury, Int. J. Care Injured 47 (2016) 11621169
including employment, consultancies, stock, ownership, honorar-
ia, paid expert testimony, patient applications/registrations and
grants or other funding related to the preparation and content of
this manuscript
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